Provider Demographics
NPI:1861038440
Name:TEMPLE, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:TEMPLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12511 S PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-7224
Mailing Address - Country:US
Mailing Address - Phone:312-826-1210
Mailing Address - Fax:
Practice Address - Street 1:12511 S PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-7224
Practice Address - Country:US
Practice Address - Phone:312-826-1210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst